Treating Kid's Sleep Apnea May Improve Behavior

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Using positive airway pressure (PAP) to treat obstructive sleep apnea in children and teens appears to improve neurobehavioral outcomes, even with suboptimal adherence, researchers found.

After three months, PAP was associated with gains in symptoms of attention deficit hyperactivity disorder (ADHD), sleepiness, behavior, and quality of life (P≤0.005 for all), according to Carole Marcus, MBBCh, of the Children's Hospital of Philadelphia, and colleagues.

The benefits also were seen in children with developmental disabilities and in those younger than 7, the researchers reported online in the American Journal of Respiratory and Critical Care Medicine.

"These improvements occurred despite a mean use of only three hours per night, suggesting that clinicians should encourage any PAP use, and not be discouraged when adherence is suboptimal," they wrote.

Action Points

This study found that using positive airway pressure (PAP) to treat obstructive sleep apnea in children and teens appears to improve neurobehavioral outcomes, even with suboptimal adherence.

Point out that the benefits were also seen in children with developmental disabilities and in those younger than 7.

"The time required for maximal improvements in behavioral function is unknown but may well be longer than three months, and further studies with long-term follow-up are needed."

Sleep apnea syndrome affects up to 4% of children, and can be associated with neurobehavioral disturbances. Most of the cases are associated with adenotonsillar hypertrophy and improve after adenotonsillectomy, although some of the children require PAP therapy.

To explore the benefits of PAP therapy on neurobehavioral outcomes, Marcus and colleagues turned to a randomized trial that compared two types of PAP delivery -- continuous PAP (CPAP) and bilevel pressure release (Bi-Flex) -- among pediatric patients with obstructive sleep apnea.

Because the two approaches had similar efficacy, the patients were combined for the current analysis, which included 52 children and teens (mean age 12).

Underlying medical conditions were common, and the most frequent were obesity (69%) and genetic syndromes (17%). Ten patients (19%) had developmental delays.

Adherence to PAP varied widely, but it was used for an average of 170 minutes per night for the three-month study. PAP improved respiratory and sleep parameters measured with polysomnography.

Despite the low overall adherence to therapy, PAP was associated with improvements in almost all of the neurobehavioral domains measured at baseline and at three months (P≤0.005 for all), including ADHD symptoms, the Epworth Sleepiness Scale, internalizing behavior symptoms and total behavior reported by caregivers, and quality of life reported both by caregivers and the patients.

The percentage of patients with scores in the abnormal range decreased significantly following three months of PAP therapy for sleepiness and quality of life.

The improvements were related to the degree of adherence for the Epworth Sleepiness Scale (P=0.0006), but not for the other outcomes.

"One reason for the lack of correlation between PAP use and other neurobehavioral outcomes in the current study may be the difference in physiologic sleep requirements over the age spectrum studied, and the differing degree of baseline neurobehavioral function in the subjects," the authors wrote.

"Thus," they wrote, "the effects of wearing CPAP for four hours a night may be less beneficial in a 2-year-old sleeping for 12 hours a night than in a 16-year-old sleeping eight hours a night."

They acknowledged some limitations of the study, including the lack of a placebo group, the inability to blind patients and caregivers to PAP treatment, and the inclusion of children and teens with a variety of ages and a variety of underlying medical conditions.

This was an investigator-initiated study funded by Philips Respironics. All data collection, statistical analyses, and manuscript writing were performed by the investigators independent of Philips Respironics. Marcus and one of her co-authors received additional grant support.

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